The Knee 16 (2009) 245–247
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The Knee
Knee stiffness following anterior cruciate ligament reconstructionThe incidence and associated factors of knee stiffness following anteriorcruciate ligament reconstruction
G.A.J. Robertson a, S.G.S. Coleman b, J.F. Keating c,⁎a The Edinburgh Orthopaedic Trauma Unit, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, United Kingdomb PESLS Department, University of Edinburgh, United Kingdomc Department of Orthopaedic Trauma, Royal Infirmary of Edinburgh, Little France, Old Dalkeith Road, Edinburgh EH16 4SU, United Kingdom
⁎ Corresponding author. Tel.: +38 0131 242 3436; faxE-mail address: [email protected] (J.F. Keating).
0968-0160/$ – see front matter © 2008 Elsevier B.V. Adoi:10.1016/j.knee.2008.12.014
a b s t r a c t
a r t i c l e i n f oArticle history:
We reviewed 100 patients Received 7 July 2008Received in revised form 16 December 2008Accepted 18 December 2008Keywords:ACL reconstructionStiffness
retrospectively following primary ACL reconstruction with quadruple hamstringautografts to evaluate the incidence and factors associated with postoperative stiffness. Stiffness was definedas any loss of motion using the contra-lateral leg as a control. The median delay between injury andoperation was 15 months.The incidence of stiffness was 12% at 6 months post-reconstruction. Both incomplete attendance atphysiotherapy (pb0.005) and previous knee surgery (pb0.005) were the strongest predictors of the stiffness.Anterior knee pain was also associated with the stiffness (pb0.029). Factors that failed to show a significantassociation with the stiffness included associated MCL sprain at injury (p=0.32), post-injury stiffness(p=1.00) and concomitant menisectomy at reconstruction (p=0.54). Timing of surgery also did not appearto influence the onset of stiffness (median delays: 29 months for stiff patients; 14 months for non-stiffpatients). The rate of stiffness fell to 5% at 12 months postreconstruction, without operative intervention.
© 2008 Elsevier B.V. All rights reserved.
1. Introduction
Several long term studies of the ACL reconstruction have reportedsuccess rates of 75% to 94% in restoring normal knee function[1–3]. Ineach of these studies, and in others[4,5], post-operative stiffness is oneof themost common complications encountered[2,4]. The incidence ofmotion loss varies from 4% to 38%, depending on the definition used todefine the presence of stiffness[2,6]. Several risk factors have beenidentified which are associated with this complication. These includemultiple-ligament injuries[7,8], insufficient delay between injury andsurgery[8], poor pre-operative range of motion[9], and poor compli-ance with post-operative rehabilitation[10].
A successful recovery is usually considered to be associated withrestoration of a full range of motionwithin 3months[2,11]. A degree ofpost-operative stiffness can be tolerated but extension loss of 5° andabove or flexion loss of 15°s and above will be unacceptable to mostpatients[12].
The aims of this studywere to define the incidence of knee stiffnessfollowing ACL reconstruction and to determine which patient factorswere associated with this.
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2. Materials and methods
We reviewed the records of 100 consecutive patients undergoinganterior cruciate ligament (ACL) reconstructions between Septem-ber 2004 and June 2006. All procedures had been performed by thesenior author. All patients had a minimum of 12 months follow-up toallow an adequate period of time elapse to detect stiffness andresponse to treatment. Of the 100 patients who underwent ACLreconstruction, 80 were male and 20 were female. The mean age ofthe cohort at reconstructionwas 30 years (range, 16 to 69 years). Theinjury was caused by football in 47 patients, rugby in 13, skiing ineight, and other sports accounted for 19 cases. Motorbike accidentsaccounted for six. Three of the injuries were work-related, and fourwere sustained as a result of falls under the influence of alcohol.
All of the patients underwent primary isolated reconstructions oftheACL and allwith quadruple hamstring autografts. Forty-six patientsunderwent menisectomy at the time of the ACL reconstruction andwere also considered suitable for inclusion (see Table 1). The mediandelay between injury and surgery was 15 months (range, 5 to300 months). There were no acute reconstructions within this cohort.For the purpose of this study, a full range ofmotion (ROM)was definedas achieving a ROM equal to the contra-lateral leg. Relevant pre-operative information, including the mechanism of injury, associatedmedial collateral sprain with injury and a history of stiffness at six
Table 1ACL reconstructions details
ACL cohort(n=100)
Stiff cohort(n=12)
Non Stiff Cohort(n=88)
Patient detailsMean age at reconstruction (years) 30 32 30Male 80 (80%) 9 (75%) 71 (81%)Female 20 (20%) 3 (25%) 17 (19%)
Patient historyMCL sprain with injury 29 (29%) 5 (42%) 24 (27%)Previous knee surgery 23 (23%) 7 (58%)⁎ 16 (18%)⁎6-week post-injury stiffness 32 (32%) 5 (42%) 27 (31%)Median surgical delay (months) 15 29 14
Surgical findingsMedial meniscal tear 36 (36%) 6 (50%) 30 (34%)Lateral meniscal tear 27 (27%) 2 (17%) 25 (28%)Chondral changes 36 (36%) 4 (33%) 32 (36%)
Surgical techniqueConcomitant meniscal surgery 46 (46%) 4 (33%) 42 (48%)
ComplicationsAnterior knee pain 17 (17%) 5 (42%)⁎ 12 (14%)⁎Patello-femoral problems 5 (5%) 2 (17%) 3 (3%)Incomplete attendance at physio. 17 (17%) 6 (50%)⁎ 11(13%)⁎
⁎=pb0.05, stiff cohort versus non-stiff cohort.
246 G.A.J. Robertson et al. / The Knee 16 (2009) 245–247
weeks post-injury, was recorded. All knees had been restored to a non-inflamed, fullymobile state prior to surgery. Patientswithmore than5°loss to full extension and less than 120° of knee flexion six weeks post-injury were considered to have a history of stiffness.
2.1. Surgical findings and technique
All ACL reconstructions were performed with an arthroscopic-assisted single incision technique. Reconstructions used a quad-ruple gracilis and semitendinosis hamstring autograft, fixed to thefemur using an endo button and to the tibia using a bioresorbablesoft tissue interference screw (DePuy Mitek Intrafix™ Screw. St.Anthony’s Road, Beeston, Leeds, LS11 8DT). Prior to each recon-struction, an arthroscopy of the knee was carried out and thepathological findings, including meniscal tears and chondral lesionswere noted in the surgical records. Ligament debridement andnotchplasty were carried out in each case prior to graft insertion.Care was taken to position tunnels correctly. At the end of theprocedure a careful assessment of knee range of motion was made,in particular to identify any evidence of graft impingement on theintercondylar notch. Post-operatively, each patient remained in acanvas splint (Actimove® Genu Eco. BSN Medical Ltd., Brierfield,BB9 5NJ, England) for 7 to 10 days until the initial pain and swellinghad settled. Patients were allowed to weight bear as soon aspossible after surgery.
Physiotherapywas commencedwithin 7 days of surgery. Patientsattended twice a week for one-to-one supervised physiotherapy forthe first 4 weeks. Following this, patients received group phy-siotherapy twice a week in a knee class for patients rehabilitatingfrom knee ligament reconstruction surgery. This continued for4 months post-operatively. Following this, the requirement forfurther rehabilitationwas determined on an individual patient basisdepending on progress. The aim within the first 2 weeks was torestore full extension and 90° of knee flexion. Closed kinetic chainexercises were allowed between weeks two and six with the aim ofstrengthening knee muscles and increasing the range of flexion to120°. Open chain exercises were introduced at 6 weeks with the goalof full restoration of knee motion by 3 months. The rehabilitationprogramme was varied depending on individual patient needs.
2.2. Post-operative progress and complications
Patients were reviewed at a specialist knee clinic at 2, 6, 12 and26 weeks after surgery, with further appointments if required. At eachclinic appointment, any clinical complications were noted and ROMrecorded. Compliance with the post-operative rehabilitation pro-gramme was recorded by the physiotherapist. The ROM was assessedby the senior author using a goniometer and using the contra-lateralleg as a control to take account for normal variations in the degree offlexion and hyperextension for each patient. Losses to extension andflexion were noted separately.
The aim of the rehabilitation programme was to restore afunctional ROM to the knee by 6 weeks post-operatively. This isdefined as a loss of extension of less than 5° and a range of flexion of atleast 110°. This range of motion is compatible with performing allroutine activities of daily living. Thus if a patient had failed to regaineither of these requirements at this stage, they were considered tohave short term stiffness. A patient who had failed to regain full ROMby 6 months post-reconstruction was then considered to have longterm stiffness. Patients were considered for arthrolysis and/or MUA ifthe range of motion remained less than the range of −5 to 140°between 4 and 6 months post-operatively.
2.3. Analysis
A univariate analysis of categorical variables considered likely toinfluence stiffness was first performed using the Chi Squared Test(with Fisher’s exact test as required). A binarymulti logistic regressionwas then performed using variables identified as significant onunivariate analysis to determine how significant these factors wereas predictors of long term stiffness.
3. Results
3.1. Stiffness after ACL reconstruction
At 6 weeks following reconstruction, 34 out of the 100 patients had failed to regaina functional ROM. There were 19 patients with extension deficits alone, seven withflexion deficits alone and eight with both.
At 6 months following reconstruction, 12 out of the 100 patients hadrestrictions to full ROM (stiff cohort). Nine had loss of extension but had regainedfull flexion, and three had residual loss of both extension and flexion. Of the 12patients in the stiff cohort, stiffness resolved between 6 and 12 months post-operatively in seven cases. These patients did not have further intervention at6 months as their ROM deficits were relatively minimal and functionallyacceptable to the patient. The remaining five patients had persistent troublesomestiffness and all of these underwent an arthroscopic arthrolysis. Two of thesepatients had achieved extension to 0 by 12 months post-reconstruction butlacked hyperextension present on the normal side, and so underwent anarthrolysis 1 and 2 years post-reconstruction respectively. In both instances,this was successful in restoring the hyperextension. The mean time to arthrolysisfor the five patients was 10 months. In four of the arthrolysis patients, the tunnelplacement was judged to be correct. In one there was anterior mal-position of thetibial tunnel which contributed to the graft impingement on the notch and loss ofextension.
3.2. Patient details and history (see Table 1)
The mean age and the gender ratio (p=0.702) of the stiff patients were similar tothose of the non-stiff patients. The median delays from injury to reconstruction were29 months (range, 6 to 163 months) in the stiff group and 14 months (range, 5 to300 months) in the non-stiff group.
Of the 23 patients who had previously undergone surgery on the knee, 12 hadpartial medial meniscectomies, three had a partial lateral meniscectomy, and eight haddiagnostic arthroscopies. The stiff cohort had a greater proportion of patients who hadundergone previous knee surgery (pb0.005), as well as a higher incidence of associatedMCL sprains at injury (p=0.322). The presence of stiffness after injury was notsignificantly associated with stiffness after reconstruction. Both the stiff and the non-stiff groups had a similar incidence of failure to regain full range of motion six-weeksfollowing injury (p=1.000).
Forty-six patients underwent concomitant medial or lateral menisectomy at thetime of surgery but this had no influence on the development of post-operativestiffness. (p=0.539). Post-operative stiffness was not related to femoral tunnel size(p=0.231) or tibial tunnel size (p=0.663).
247G.A.J. Robertson et al. / The Knee 16 (2009) 245–247
3.3. Complications (see Table 1)
The stiff cohort had significantly poorer attendance at physiotherapy as comparedto the non-stiff cohort (pb0.005). Patients with stiffness also noted an increasedincidence of anterior knee pain (pb0.029) and patello-femoral problems (p=0.108).
3.4. Binary logistic regression for long term stiffness
Previous knee surgery, incomplete attendance at physiotherapy and anterior kneepain during rehabilitation were used as the categorical predictors in the binary logisticregression. Incomplete attendance at physiotherapy (Exp(B)=6.931; 95% CI, 1.609–29.859; pb0.009) and previous knee surgery (Exp(B)=6.383; 95% CI, 1.548–26.322;pb0.010) were both found to be significant predictors of long term stiffness. Anteriorknee pain was not found to be a significant predictor for this condition. (Exp(B)=3.254; 95% CI, 0.741–14.289; p=0.118).
4. Discussion
In this study we found an incidence of stiffness of 12% 6 monthspost-ACL reconstruction. However the incidence of stiffness 1 yearafter reconstruction had dropped to 5% following conservativemanagement of the problem. Patients who demonstrated poorcompliance with the post-operative rehabilitation programme andthose who had had previous surgery on the knee were most at risk ofdeveloping the stiffness. Patients with the stiffness were also noted tohave an increased incidence of anterior knee pain during rehabilita-tion. The stiffness was not related to timing of surgery but this may bea consequence of the 4 month delay prescribed as a minimum for allpatients between injury and reconstruction. All operations wereperformed at least 4 months after injury on fully mobile knees. Otherfactors which failed to show significant links to the stiffness includedage, sex and associated MCL sprain at injury. The addition ofmenisectomy to the procedure did not influence postoperativestiffness either. Our rate of menisectomy may be considered some-what high but this reflects a relatively long period of time betweeninjury and the ACL reconstruction. Most tears encountered were notsuitable for repair as they were chronic at the time of surgery.
The incidence of stiffness at 6monthswas similar to that reported byother authors who defined motion loss in the same way (9%[13], 12%[14]). Kartus et al.[2], noted that, provided therewere no technical errorsat the time of reconstruction, an effective rehabilitationprogrammewasthe most important factor in regaining full ROM post-reconstruction.The arthrolysis rate of 5% may seem high but reflects an interventionalpolicy of treating stiffness after ACL reconstruction in our unit.
In previous studies, an association has been found betweeninsufficient delay from injury to surgery and the development of thestiffness[8,14]. The results of this study, in addition to those of Kartuset al.[2], would suggest that a delay of around three months isbeneficial to minimising the risk of stiffness. This delay may well havebeen the main reason why the link between MCL sprain at injury andthe stiffness was not significant in this or in the study of Petersen &Laprell[15]. Similarly, by allowing the patients to restore a full ROMprior to reconstruction, it may also be the reason there was noassociation between post-injury stiffness and post-operative stiffness.This differed from the finding of Cosgarea et al.[9], who noted an
association but operated at an earlier stage post injury on theirpatients. In accordance with previous studies[8,11,16], a significantlink was found between long term stiffness and anterior knee pain.This is probably because the knee pain is a consequence of thestiffness rather than being causally related to the development ofpost-operative stiffness.
5. Conclusion
The early incidence of knee stiffness after primary ACL reconstruc-tion is 12%. Poor compliance with post-operative rehabilitation andprevious surgery on the knee were both found to be the strongestpredictors of the problem. The rate of stiffness fell to 5% at 12 months,without operative intervention.
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